Balance of Care

While actual percentages or numbers are arbitrary, I would generally agree with the 50/25/25 approach of primary, specialty, and hospital services, respectively.  However, a stronger primary care system seems to be a proven benefit to public health, regardless of the actual values.  Astoundingly, in one study described in the International Journal of Health Services, an increase in primary care physicians contributed to everything from improved “all-cause” health outcomes to decreases in low birth weights, higher patient satisfaction, and even lower mortality rates.  In fact, they provided evidence that showed “an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3%...” If nothing else, primary care acts as a necessary gatekeeper to the seemingly more desirable specialty care, which would be an ineffective and inefficient first line of defense.

Additionally, I thought that was a very good point made about the mindset of the current medical environment.  It caused me to realize of all the conversations I have had with friends or acquaintances pursuing a career in medicine, I cannot recall a single person who expressed an interest in being a primary care physician. I personally considered going to medical school and the one question I remember being asked most often was “What do you want to specialize in?”  It appears as if it is almost inconceivable that someone would actually seek to remain in primary care!  According to a number of journal articles, the interest in primary care careers has dropped from 36% in 1982 to 14% in 1995, 8% in 2005, and finally to 2% in 2008 (a thank-you to Ramon for the most current percentage).  Currently more than ¾ of all internal medicine residents migrate away from primary care.

The income disparity (specialists make, on average, nearly 2.5 times more) and re-imbursement rate (insurers tend to reimburse an average of 170% more for specialty services) seems to be the most frequently documented reason for this drastic and ever-increasing shift.  However, I also came across other perks to specialization including a tendency for more predictable work hours and greater prestige among colleagues.  With so much stacked against primary care it seems, both figuratively and literally, like choosing the Ford Taurus over the Aston Martin.

 Sources:

Macinko J, Starfield B, Shil L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37(1):111-26. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/17436988

Zajicek G. Benefits of primary care. Nature. 194 Aug 18;370(6490):501http://www.nature.com/nature/journal/v371/n6498/pdf/371552a0.pdf

Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007;146:301-306. http://www.annals.org/cgi/reprint/146/4/301.pdf

Shil L. Balancing primary versus specialty care. J R Soc Med. 1995;88:428-432. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1295294&blobtype=pdf